VNS Health Logo
1-866-986-7691

Consent and Authorization

VNS Health Consent and Authorization Agreement

I hereby authorize VNS Health, its affiliates and their respective licensees, successors and assigns, the right without limitation and in perpetuity, to use, reproduce, record, edit and publish my name and all photographs, videotapes, audiotapes, movies and/or content submitted with this form, and/or content agreed upon after interviews with VNS Health editorial staff (all such content referred to as “Publications”). If I am a patient and/or client of VNS Health, I understand that this may include health information about me and which may be considered protected health information (“PHI”) under the Health Insurance Portability and Accountability Act (“HIPAA”), Privacy Rule or under state law, and may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV/AIDS-RELATED INFORMATION only if I place my initials on the appropriate line below. In the event the health information disclosed includes any of these types of information, and I initial the line on the box below, I specifically authorize the release of such information. If I am an employee, contractor, consultant, volunteer and/or fellow of VNS Health, I understand that this authorization includes publishing of my identification of me having such status with VNS Health. Such material may be used in advertising and promotion of VNS Health and/or for fundraising purposes in any medium existing now or hereafter created (such as, for example, the Internet, social media, newspapers, television or radio).

I agree that all Publications of me and/or the story used and/or taken by VNS Health and all rights therein and thereto, including all copyrights, trademarks, and all other tangible and intangible rights, shall be owned by VNS Health, and VNS Health shall be entitled to use, assign, or otherwise exploit the Publications in any manner and in all media, now existing or subsequently developed, throughout the world in perpetuity. If I receive any print, negative or other copy of the Publications, I shall not authorize use of it for any commercial purpose nor authorize its use by anyone else.

Nothing herein will constitute any obligation on the part of VNS Health to make any use of the Publications or the rights set forth herein.

I will make no financial claims for the use of the Publications and I understand that no special compensation will be provided to me for the use of the Publications. I understand that I may not be informed in advance of the specific use(s) of the Publications. VNS Health will not condition continued employment, contracting, association, treatment, payment, enrollment or eligibility for benefits on whether or not you sign this authorization.

I can revoke this authorization at any time before VNS Health has relied upon it by writing to the VNS Health Marketing Group, but VNS Health may use and disclose this information to the extent VNS Health has relied upon the authorization, which may occur after VNS Health prepares work product from the information received from me. Once that occurs, it is not possible to revoke my authorization.

Disclosure of Information

VNS Health may disclose information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV/AIDS-RELATED INFORMATION - ONLY if I check the box on the appropriate line below. If you prefer that this information remains confidential, do not check any of the boxes.

Name(Required)
MM slash DD slash YYYY
I Agree to this Consent and Authorization Agreement(Required)
This field is for validation purposes and should be left unchanged.